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Coronary obstruction following transcatheter aortic valve implantation.

Ribeiro HB, Sarmento-Leite R, Siqueira DA, Carvalho LA, Mangione JA, Rodés-Cabau J, Perin MA, Brito FS - Arq. Bras. Cardiol. (2014)

Bottom Line: In one patient, with pre-procedural computed tomography data, coronary arteries presented a low height and a narrow sinus of Valsalva.All patients presented with clinically significant severe maintained hypotension, immediately after valve implantation, and even though coronary angioplasty with stent implantation was successfully performed in all cases, patients died during hospitalization, being two periprocedurally.Anatomical factors might be related with its increased occurrence, highlighting the importance of a good pre-procedural evaluation of the patients in order to avoid this severe complication.

View Article: PubMed Central - PubMed

Affiliation: Laval University, Quebec Heart & Lung Institute, Quebec, Canadá

ABSTRACT

Background: Transcatheter aortic valve implantation (TAVI) was established as an important alternative for high-risk patients with severe aortic stenosis. However, there are few data in the literature regarding coronary obstruction, that although rare, is a potentially fatal complication.

Objective: Evaluate this complication in Brazil.

Methods: We evaluated all patients presenting coronary obstruction from the Brazilian Registry of TAVI. Main baseline and procedural characteristics, management of the complication, and clinical outcomes were collected from all patients.

Results: From 418 consecutive TAVI procedures, coronary obstruction occurred in 3 cases (incidence of 0.72%). All patients were women, without prior coronary artery bypass grafting (CABG), and with mean age of 85 ± 3 years, logistic EuroSCORE of 15 ± 6% and STS-PROM score of 9 ± 4%. All of the cases were performed with balloon-expandable Sapien XT prosthesis. In one patient, with pre-procedural computed tomography data, coronary arteries presented a low height and a narrow sinus of Valsalva. All patients presented with clinically significant severe maintained hypotension, immediately after valve implantation, and even though coronary angioplasty with stent implantation was successfully performed in all cases, patients died during hospitalization, being two periprocedurally.

Conclusion: Coronary obstruction following TAVI is a rare but potentially fatal complication, being more frequent in women and with the balloon-expandable prosthesis. Anatomical factors might be related with its increased occurrence, highlighting the importance of a good pre-procedural evaluation of the patients in order to avoid this severe complication.

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Computed tomography with height measurement of coronary arteries in long-axisview, showing right coronary artery (a) and left coronary artery (b). Sinus ofValsalva measurement obtained from the mean between the larger and smallestdiameter on short-axis view (c). Aortography showing occlusion of rightcoronary artery after transcatheter aortic valve implantation (d). Angiographyof right coronary artery after successful implantation of two stents (e).
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f01: Computed tomography with height measurement of coronary arteries in long-axisview, showing right coronary artery (a) and left coronary artery (b). Sinus ofValsalva measurement obtained from the mean between the larger and smallestdiameter on short-axis view (c). Aortography showing occlusion of rightcoronary artery after transcatheter aortic valve implantation (d). Angiographyof right coronary artery after successful implantation of two stents (e).

Mentions: A 83-year-old female, hypertensive, diabetic, with coronary artery disease and heartfailure functional class III (NYHA). In clinical evaluation, it was noted severeaortic stenosis (mean gradient: 77 mmHg; valve area: 0.50 cm2) of highrisk (logistic EuroSCORE: 9.5%; STS PROM: 7.9%) being referred to TAVI. Onangiotomography it was verified the sinus of Valsalva with mean diameter of 26 mm,valve annulus of 24 mm and height of right coronary artery (RCA) and left main (LM)of 10.4 mm and 9.6 mm, respectively (Figure 1).The procedure was performed by transfemoral approach, with implantation of a 26 mmballoon-expandable Sapien XT prosthesis. Immediately after valve implantation, thepatient evolved with severe and maintained hypotension, in addition to ST-segmentelevation detected on cardiac monitoring. Transesophageal echocardiogram (TEE) showedappropriate bioprosthesis positioning, with mild perivalvular regurgitation. Onaortography it was detected complete obstruction of RCA ostium (Figure 1). A condition of shock and cardiac arrest had quicklybegun, so that cardiopulmonary resuscitation and angioplasty with implantation of 2drug-eluting stent of the RCA were successfully performed (Figure 1). As a further complication, due to resuscitationprocedures, there was a perforation on right ventricle by temporary pacemaker andtamponade, and despite the treatment of the complications, there was another cardiacarrest and subsequent death.


Coronary obstruction following transcatheter aortic valve implantation.

Ribeiro HB, Sarmento-Leite R, Siqueira DA, Carvalho LA, Mangione JA, Rodés-Cabau J, Perin MA, Brito FS - Arq. Bras. Cardiol. (2014)

Computed tomography with height measurement of coronary arteries in long-axisview, showing right coronary artery (a) and left coronary artery (b). Sinus ofValsalva measurement obtained from the mean between the larger and smallestdiameter on short-axis view (c). Aortography showing occlusion of rightcoronary artery after transcatheter aortic valve implantation (d). Angiographyof right coronary artery after successful implantation of two stents (e).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3987397&req=5

f01: Computed tomography with height measurement of coronary arteries in long-axisview, showing right coronary artery (a) and left coronary artery (b). Sinus ofValsalva measurement obtained from the mean between the larger and smallestdiameter on short-axis view (c). Aortography showing occlusion of rightcoronary artery after transcatheter aortic valve implantation (d). Angiographyof right coronary artery after successful implantation of two stents (e).
Mentions: A 83-year-old female, hypertensive, diabetic, with coronary artery disease and heartfailure functional class III (NYHA). In clinical evaluation, it was noted severeaortic stenosis (mean gradient: 77 mmHg; valve area: 0.50 cm2) of highrisk (logistic EuroSCORE: 9.5%; STS PROM: 7.9%) being referred to TAVI. Onangiotomography it was verified the sinus of Valsalva with mean diameter of 26 mm,valve annulus of 24 mm and height of right coronary artery (RCA) and left main (LM)of 10.4 mm and 9.6 mm, respectively (Figure 1).The procedure was performed by transfemoral approach, with implantation of a 26 mmballoon-expandable Sapien XT prosthesis. Immediately after valve implantation, thepatient evolved with severe and maintained hypotension, in addition to ST-segmentelevation detected on cardiac monitoring. Transesophageal echocardiogram (TEE) showedappropriate bioprosthesis positioning, with mild perivalvular regurgitation. Onaortography it was detected complete obstruction of RCA ostium (Figure 1). A condition of shock and cardiac arrest had quicklybegun, so that cardiopulmonary resuscitation and angioplasty with implantation of 2drug-eluting stent of the RCA were successfully performed (Figure 1). As a further complication, due to resuscitationprocedures, there was a perforation on right ventricle by temporary pacemaker andtamponade, and despite the treatment of the complications, there was another cardiacarrest and subsequent death.

Bottom Line: In one patient, with pre-procedural computed tomography data, coronary arteries presented a low height and a narrow sinus of Valsalva.All patients presented with clinically significant severe maintained hypotension, immediately after valve implantation, and even though coronary angioplasty with stent implantation was successfully performed in all cases, patients died during hospitalization, being two periprocedurally.Anatomical factors might be related with its increased occurrence, highlighting the importance of a good pre-procedural evaluation of the patients in order to avoid this severe complication.

View Article: PubMed Central - PubMed

Affiliation: Laval University, Quebec Heart & Lung Institute, Quebec, Canadá

ABSTRACT

Background: Transcatheter aortic valve implantation (TAVI) was established as an important alternative for high-risk patients with severe aortic stenosis. However, there are few data in the literature regarding coronary obstruction, that although rare, is a potentially fatal complication.

Objective: Evaluate this complication in Brazil.

Methods: We evaluated all patients presenting coronary obstruction from the Brazilian Registry of TAVI. Main baseline and procedural characteristics, management of the complication, and clinical outcomes were collected from all patients.

Results: From 418 consecutive TAVI procedures, coronary obstruction occurred in 3 cases (incidence of 0.72%). All patients were women, without prior coronary artery bypass grafting (CABG), and with mean age of 85 ± 3 years, logistic EuroSCORE of 15 ± 6% and STS-PROM score of 9 ± 4%. All of the cases were performed with balloon-expandable Sapien XT prosthesis. In one patient, with pre-procedural computed tomography data, coronary arteries presented a low height and a narrow sinus of Valsalva. All patients presented with clinically significant severe maintained hypotension, immediately after valve implantation, and even though coronary angioplasty with stent implantation was successfully performed in all cases, patients died during hospitalization, being two periprocedurally.

Conclusion: Coronary obstruction following TAVI is a rare but potentially fatal complication, being more frequent in women and with the balloon-expandable prosthesis. Anatomical factors might be related with its increased occurrence, highlighting the importance of a good pre-procedural evaluation of the patients in order to avoid this severe complication.

Show MeSH
Related in: MedlinePlus